A 54-year-old man is evaluated on the inpatient medical ward 12 hours after being admitted… — USMLE Step 3

A $54$ -year-old man is evaluated on the inpatient medical ward $12$ hours after being admitted for increased abdominal girth, low-grade fever, and mild confusion. He has a history of decompensated cirrhosis due to chronic hepatitis C infection and alcohol use disorder. Temperature is $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), pulse is $98/\text{min}$ , and blood pressure is $105/65 \text{ mmHg}$ . Physical examination reveals scleral icterus, spider angiomas, and tense ascites with shifting dullness. Asterixis is present.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Platelet count: $85,000/\text{mm}^3$
Blood urea nitrogen: $42 \text{ mg/dL}$
Serum creatinine: $2.3 \text{ mg/dL}$ (Baseline $3$ months ago was $1.1 \text{ mg/dL}$ )
Total bilirubin: $4.5 \text{ mg/dL}$
Serum albumin: $2.4 \text{ g/dL}$

Diagnostic paracentesis is performed, and ascitic fluid analysis reveals an absolute neutrophil count of $650/\text{mm}^3$ and total protein of $1.2 \text{ g/dL}$ . The patient is immediately started on intravenous cefotaxime and oral lactulose.

Which of the following is the most appropriate additional pharmacologic intervention at this time?

A
Intravenous furosemide and spironolactone
Intravenous albuminCevap
C
Oral midodrine and subcutaneous octreotide
D
Intravenous hydrocortisone
E
Oral propranolol

Cevap

Intravenous albumin

The correct answer is intravenous albumin. This patient has spontaneous bacterial peritonitis (SBP), diagnosed by an ascitic fluid absolute neutrophil count

\geq 250/\text{mm}^3

. SBP is a common precipitant of hepatorenal syndrome (HRS), a form of acute kidney injury caused by severe splanchnic arterial vasodilation and subsequent renal vasoconstriction. To mitigate this risk, patients with SBP should receive intravenous albumin (

1.5 \text{ g/kg}

on day 1 and

1.0 \text{ g/kg}

on day 3) if they meet any of the following high-risk criteria: serum creatinine

> 1.0 \text{ mg/dL}

, blood urea nitrogen

> 30 \text{ mg/dL}

, or total bilirubin

> 4.0 \text{ mg/dL}

. This patient meets all three criteria. Albumin acts as a plasma volume expander, improving effective circulating arterial volume and renal perfusion, which significantly reduces both the incidence of HRS and overall mortality.

Adım Adım Çözüm

Diagnose the primary acute pathology based on ascitic fluid analysis.

The patient has spontaneous bacterial peritonitis (SBP), confirmed by an ascitic fluid absolute neutrophil count (ANC)

\geq 250/\text{mm}^3

Identifying SBP is the first step in directing targeted antimicrobial and adjunctive therapies.

Assess the patient's renal function and associated laboratory parameters.

The patient has acute kidney injury (creatinine elevated to

2.3 \text{ mg/dL}

from

1.1 \text{ mg/dL}

), elevated BUN (

42 \text{ mg/dL}

), and elevated bilirubin (

4.5 \text{ mg/dL}

SBP frequently triggers a systemic inflammatory response that worsens splanchnic vasodilation, leading to profound renal hypoperfusion and hepatorenal syndrome (HRS).

Select the appropriate adjunctive pharmacologic therapy to prevent renal failure.

Intravenous albumin is indicated.

Guidelines require the administration of intravenous albumin (

1.5 \text{ g/kg}

on day 1, and

1.0 \text{ g/kg}

on day 3) for SBP patients who have a serum creatinine

> 1.0 \text{ mg/dL}

, BUN

> 30 \text{ mg/dL}

, or total bilirubin

> 4.0 \text{ mg/dL}

to expand intravascular volume, prevent HRS, and reduce mortality.

Anahtar Kavram

Patients with spontaneous bacterial peritonitis (SBP) who have concurrent renal impairment (creatinine

> 1.0 \text{ mg/dL}

, BUN

> 30 \text{ mg/dL}

) or severe liver disease (bilirubin

> 4.0 \text{ mg/dL}

) require adjunctive intravenous albumin on days 1 and 3 to prevent hepatorenal syndrome and reduce mortality.

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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